Implementation and enforcement of smoke-free policies in public housing

Variability in self-reported and biomarker-derived tobacco smoke exposure patterns among individuals who do not smoke by poverty income ratio in the USA

INTRODUCTION

Tobacco smoke exposure (TSE) among individuals who do not smoke has declined in the USA, however, gaps remain in understanding how TSE patterns across indoor venues-including in homes, cars, workplaces, hospitality venues, and other areas-contribute to TSE disparities by income level.

METHODS

We obtained data on adults (ages 18+, N=9909) and adolescents (ages 12-17, N=2065) who do not smoke from the National Health and Nutrition Examination Survey, 2013-2018. We examined the prevalence of self-reported, venue-specific TSE in each sample, stratified by poverty income ratio (PIR) quartile. We used linear regression models with a log-transformed outcome variable to explore associations between self-reported TSE and serum cotinine. We further explored the probability of detectable cotinine among individuals who reported no recent TSE, stratified by PIR.

RESULTS

Self-reported TSE was highest in cars (prevalence=6.2% among adults, 14.2% among adolescents). TSE in own homes was the most strongly associated with differences in log cotinine levels (β for adults=1.92, 95% CI=1.52 to 2.31; β for adolescents=2.37 95% CI=2.07 to 2.66), and the association between home exposure and cotinine among adults was most pronounced in the lowest PIR quartile. There was an income gradient with regard to the probability of detectable cotinine among both adults and adolescents who did not report recent TSE.

CONCLUSIONS

Homes and vehicles remain priority venues for addressing persistent TSE among individuals who do not smoke in the USA. TSE survey measures may have differential validity across population subgroups.

The impact of smoke-free policies on smoking at outdoor sports clubs: a qualitative study

OBJECTIVES

Smoking may still occur at sports clubs with an outdoor smoke-free policy (SFP). This study aims to map the occurrence of smoking at various sports clubs in the Netherlands and to understand why smoking occurs at some clubs but not at others.

STUDY DESIGN

This was a qualitative design in the form of semistructured interviews.

METHODS

Semistructured interviews (n = 34) were held online with smoking and non-smoking members of 17 Dutch outdoor sports clubs (in field hockey, korfball, football, and tennis) with an outdoor SFP. Data were analyzed using content analysis.

RESULTS

We identified four situations where smoking still occurred: (1) directly at the entrance, (2) at some distance from the entrance, (3) in particular places on the premises, and (4) in various places or on occasions when alcohol is consumed. Smoking directly at the entrance was most often perceived as a bothersome situation that was difficult to avoid. The occurrence of these situations differed per sports club depending on the scope of the SFP (the comprehensiveness of the SFP and the presence or absence of a smoking area) and factors influencing policy compliance (physical characteristics of the sports club's premises, the presence or absence of children, and several enforcement difficulties).

CONCLUSION

In some sports clubs, smoking remained common on the premises despite an outdoor SFP. Exposure to second-hand smoke might be reduced by formulating a comprehensive SFP, improving policy compliance also in situations where children are absent, and organizing the enforcement of the policy.

Implementation Activities in Smoke-Free Public Housing: The Massachusetts Experience

A 2018 rule requiring federally-subsidized public housing authorities (PHAs) in the United States to adopt smoke-free policies (SFPs) has sparked interest in how housing agencies can best implement SFPs. However, to date, there is little quantitative data on the implementation of SFPs in public housing. Massachusetts PHAs were among the pioneers of SFPs in public housing, and many had instituted SFPs voluntarily prior to the federal rule. The aim of this study was to examine the adoption, implementation, and outcomes of SFPs instituted in Massachusetts PHAs prior to 2018 using a survey conducted that year. The survey asked if PHAs had SFPs and, if so, what activities were used to implement them: providing information sessions, offering treatment or referral for smoking cessation, soliciting resident input, training staff, partnering with outside groups, using a toolkit, and/or providing outdoor smoking areas. We used multivariable regression to investigate associations between implementation activities and respondent-reported policy outcomes (resident support, complaints about neighbors' smoking, and the number of violations reported per year). Of 238 Massachusetts PHAs, 218 (91%) completed the survey and 161 had an SFP prior to 2018. Common implementation activities were offering smoking cessation treatment/referral (89%) and information sessions for residents (85%). Information sessions for residents were associated with higher resident support (adjusted odds ratio [AOR] 4.3; 95%CI 1.2-15.3). Training staff (AOR 6.3, 95%CI 1.2-31.8) and engaging in ≥5 implementation activities (AOR 4.1, 95%CI 1.2-14.1) were associated with fewer smoking-related complaints. Utilization of multiple implementation activities, especially ones that informed residents and trained PHA staff, was associated with more favorable policy outcomes. We identified five groups of PHAs that shared distinct patterns of SFP implementation activities. Our findings, documenting implementation activities and their associations with SFP outcomes among the early adopters of SPFs in Massachusetts public housing, can help inform best practices for the future implementation of SFPs in multiunit housing.

Assessing Smoke-Free Housing Implementation Approaches to Inform Best Practices: A National Survey of Early-Adopting Public Housing Authorities

Secondhand smoke (SHS) exposure causes chronic illness and occurs at a higher prevalence in low-income communities than the general public. In 2018, the U.S. Department of Housing and Urban Development (HUD) instituted a smoke-free housing rule for Public Housing Authorities (PHAs) to address persistent health inequities. However, the success of smoke-free housing requires evidence to inform effective implementation approaches. A mixed-methods, cross-sectional survey was conducted in a national sample of PHAs. Questions focused on housing officials' use of specific implementation strategies. Adjusted odds ratios were used to assess associations between implementation approaches and variations among PHAs (i.e., region, size, or recency of policy adoption). Qualitative analyses were conducted to assess the perceived effectiveness of implementation strategies. Resident engagement, staff training, and smoking cessation support were the most frequently used implementation strategies. Engagement with local stakeholders was cited less frequently. Enforcement actions were limited with no violations referred to housing court. Support for policy adherence was identified as a sixth implementation strategy. While most PHAs used at least some evidence-informed implementation strategies, a lack of a systematic approach may limit overall effectiveness. Further research is required to resolve implementation barriers experienced disproportionately by a subset of PHAs, and to inform a best practice implementation framework that meets the needs of a heterogeneous population.

Applying Theory to Explain the Influence of Factors External to an Organization on the Implementation of an Evidence-Based Intervention

Despite its widely acknowledged influence on implementation, limited research has been done on how the external environment (i.e., outer setting) determines when organizations adopt and implement new interventions. Determinant frameworks identify several outer setting-level factors such as funding streams, inter-organizational relationships, and peer pressure. However, these frameworks do not explain how or why outer-setting factors influence implementation. To advance research in this area, we argue for the importance of deriving theory-based propositions from organization theory to explain how outer setting factors influence organizations. Drawing on the work of the Organization Theory in Implementation Science (OTIS) project, we identified 20 propositions from five classic organization theories-Complexity Theory, Contingency Theory, Institutional Theory, Resource Dependence Theory, and Transaction Cost Economics. We then applied those propositions to hypothesize relationships among outer setting factors, implementation strategies, and implementation outcomes in five case studies of evidenced-based tobacco control interventions. The five case studies address the implementation of smoke-free policies, community health worker-led tobacco education and cessation programs, 5 A's (Ask, Advise, Assess, Assist, and Arrange), point-of-sale tobacco marketing policy interventions, and quitlines. The case studies illustrate how propositions may be used to guide the selection and testing of implementation strategies. Organization theories provide a menu of propositions that offer guidance for selecting and optimizing high-leverage implementation strategies that target factors at the level of outer setting. Furthermore, these propositions suggest testable hypotheses regarding the mechanisms underlying the influence of outer-setting factors on how and why organizations adopt and implement interventions.

Tobacco Smoke Exposure and Urinary Cadmium in Women from Northern Mexico

Cadmium (Cd), a carcinogenic metal also related to reproductive and cardiovascular diseases, is contained in tobacco and elevated concentrations of it in humans have been consistently associated with first-hand tobacco smoke; however, there is scarce and inconclusive evidence of the relationship between Cd and secondhand smoke (SHS) exposure. Our aim was to evaluate the association between exposure to tobacco, both active and SHS, with urinary Cd concentrations in Mexican women. In a cross-sectional analysis that included 998 women living in northern Mexico, we measured the concentration of creatinine-adjusted urinary Cd (µg-cadmium/g-creatinine) using inductively coupled plasma triple quadrupole (ICP-QQQ) in tandem mass spectrometry mode (MS/MS). We gathered tobacco smoking information through an in-person interview and formed seven groups: non-smokers without SHS exposure; non-smokers with SHS exposure; ex-smokers without SHS exposure <1 year of quitting; ex-smokers without SHS exposure ≥1 year of quitting, ex-smokers with SHS exposure <1 year of quitting; ex-smokers with SHS exposure ≥1 year of quitting and current smokers. The interview also yielded sociodemographic characteristics. We used linear multivariable regression models to estimate the association between Cd concentrations and tobacco smoke exposure. Compared to non-smokers without SHS exposure, we found higher Cd concentrations in ex-smokers with SHS exposure <1 year of quitting and current smokers (adjusted geometric means 0.51 vs. 1.01 and 0.69 µg-cadmium/g-creatinine, respectively). Our results do not support a conclusion that SHS exposure is a source of Cd body burden.

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis

BACKGROUND

Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy.

METHODS

In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563.

FINDINGS

We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I² 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy.

INTERPRETATION

Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health.

FUNDING

Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.

A qualitative study of the process of adoption, implementation and enforcement of smoke-free policies in privately-owned affordable housing

Background

Household smoke-free home rules cannot fully protect nonsmokers from secondhand smoke (SHS) if they live in multi-unit housing (MUH). Instead, property-level smoke-free policies are needed to prevent SHS incursion into apartment units and to keep common areas smoke-free. Smoke-free policies are usually at the discretion of property management companies and owners within the context of market-rate and privately-owned affordable housing in the U.S.

Methods

Semi-structured interviews on the policy development, implementation and enforcement experiences of 21 different privately-owned affordable housing management companies were conducted with representatives from properties in North Carolina and Georgia who had established smoke-free policies before 2016.

Results

The decision to adopt was typically made by corporate leadership, board members, owners or property managers, with relatively little resident input. Policy details were influenced by property layout, perceptions of how best to facilitate compliance and enforcement, and cost of creating a designated smoking area. Policies were implemented through inclusion in leases, lease addenda or house rules with 6 months’ notice most common. Participants thought having a written policy, the norms and culture of the housing community, public norms for smoke-free environments, and resident awareness of the rules and their consequences, aided with compliance. Violations were identified through routine inspections of units and resident reporting. Resident denial and efforts to hide smoking were shared as challenges to enforcement, along with a perception that concrete evidence would be needed in eviction court and that simply the smell of SHS was insufficient evidence of violation. Over half had terminated leases or evicted residents due to violations of the smoke-free policy. The most common benefits cited were reduced turnover cost and time, and lower vacancy rates.

Conclusions

Understanding the smoke-free policy process in privately-owned affordable housing can help practitioners encourage policies within subsidized housing contexts. The study identified salient benefits (e.g., reduced cost, time, and vacancies) that can be highlighted when encouraging MUH partners to adopt policies. Additionally, study findings provide guidance on what to consider when designing smoke-free policies (e.g., layout, costs), and provide insights into how to enhance compliance (e.g., resident awareness) and manage enforcement (e.g., routine inspections).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7404-y) contains supplementary material, which is available to authorized users.